1.

GELLER: On July 1, 1977, I began an NIMH-sponsored Fellowship titled: “Psychiatry in Primary Care.” I was a psychiatrist embedded in the Beth Israel Ambulatory Care clinic, one of the first of its kind in the USA. Thus, I have been aware of the efforts at integration for over 30 years. APA has made baby steps. APA’s next steps: 1) APA is offering free training in the Collaborative Care Model for psychiatrists under the CMS Transforming Clinical Practice Initiative. APA needs to publicize this much more effectively to its members. APA needs to encourage all members to engage in this training as an understanding of the model will benefit a psychiatrist no matter what setting she/he is practicing in; 2) The Institute on Psychiatric Services has had sessions on integrated medicine. The meeting should expand these offerings to a track on integrated medicine, increase its appeal to non-psychiatric physicians and market it to them; 3) In 2016, APA and ACLP (then the APM) issued a report reviewing the scientific evidence for integrated care and providing recommendations for advancing the use of the model. This should be an annual report and should be printed in the American Journal of Psychiatry.

MISKIMEN: From commissioning the 2014 report that highlighted the financial advantages of effective behavioral health care integration to developing and implementing an integrated care training program for psychiatrists, primary care physicians and care managers, the American Psychiatric Association (APA) has, and will continue to play, a crucial role in new and innovative care models. In my opinion, one of the biggest hurdles for our organization is to effectively collaborate with the appropriate stakeholders, including HRSA, SAMHSA and CMS, to develop and implement viable payment models for mental health and addiction services. This task will also require a change in policies to remove roadblocks that are currently preventing our members from participating in Advanced Alternative Payment Models (APMs).

The APA has a strong track record in promoting collaboration with non-psychiatric medical organizations to advance health care solutions affecting our members and those we serve. For example, I participated in one such endeavor with five other frontline medical groups—the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American College of Physicians and the American Osteopathic Association—in meeting with key bipartisan legislators urging them to strive for solutions to strengthen and improve the health insurance market and treatment access for mental health and substance use disorders as essential health benefits. The group called on legislators to take immediate action to enact a five-year extension of funding for the Children’s Health Insurance Program (CHIP) ensuring ongoing access to this crucial affordable and comprehensive coverage option for millions of children and pregnant women. The APA is thus positioned to foster and strengthen these and other interdisciplinary relationships creating an advantage in resource pooling to enact health integration solutions. One possibility would be to collaborate in developing and implementing specific educational protocols and programs to disseminate the the advantages of integrated care.

2.

GELLER: The future of psychiatry is the integrated care of most psychiatric disorders in primary care settings and the targeted care of severe mental illness in specialty settings like state hospitals. As the medical director of Massachusetts’ largest public psychiatric hospital (Worcester Recovery Center and Hospital (WRCH)), I think WRCH has an exemplary model of integrated care. ACLP, CoCLP and APA should be broadening the understanding of where integrated care actually occurs and how the model can work, with variations, across the spectrum of practice locations. Can a psychoanalyst practice integrated care? Sure—if it’s framed right. Freud certainly tried. ACLP members are the experts in integrated care because it’s fundamental to the work. ACLP needs to leverage APA’s breadth and scope to lead and teach APA members about the ubiquity of integrated care and teach them how to do it more effectively. ACLP could be pushing for greater representation at the annual meeting. ACLP could consider seeking grants from the American Psychiatric Association Foundation to train psychiatrists in rural areas in integrated care to expand their ability to see greater numbers of patients because psychiatrists are scarce. Finally, ACLP might make the case to the APA that integrated care is part of the push back to psychologists prescribing.

MISKIMEN: The 2016 “Dissemination of Integrated Care within Adult Primary Care Settings: The Collaborative Model” is a great example of what the ACLP and the APA can accomplish together. This comprehensive report aligned the strategic goals of both organizations at the same time that it provided a roadmap for the development and implementation of this model of care. I believe that this partnership will continue to flourish over the upcoming years, especially as the recommendations provided in the report are enacted in the areas of education, training, implementation support and payment reform. Furthermore, the ACLP, as the subject matter expert, may spearhead initiatives to expand integrated care beyond primary care settings to areas such as surgical and palliative care as a normal progression of the models being developed at present.

3.

GELLER: Fellowship training is a valuable addition to psychiatrists’ training. Residents, however, should not feel that something is wrong with them if they choose not to go from residency directly into a fellowship. This month I interviewed a PGY 4 resident from the UMASS program who was interviewing for a public sector position. She is the chief resident this year. She told me, “I’m the only in my year who is graduating.” She was, in part, second guessing herself and this shouldn’t be. Psychiatry needs subspecialists; psychiatry needs generalists. There are fellowships that actually train psychiatrists to do both. The Public Sector Psychiatry Fellowship is a good example. Within the fellowship world we should be maximizing flexibility.

MISKIMEN: As an educator, it is a privilege to prepare the next generation of psychiatrists for the challenges that lie ahead for our profession. While psychiatry has not seen the rapid proliferation of subspecialties as other areas in medicine, the rapid expansion of knowledge-base over the past 50 years has created a demand for specialization. It is thus critical to advocate and secure a robust training mission that prepares each trainee to deliver care aligned with the triple aim of improving the experience of care, health outcomes, while reducing costs.

4.

GELLER: I am not in favor of fast tracking psychiatry training. A good subspecialist needs an excellent grounding in general psychiatry. If I was in residency and I wanted to do a C-L fellowship, what would I skip? I would suggest the resident who knows he doing a fellowship in one subspecialty should spend very little time in elective rotations in that subspecialty and get a grounding in other areas of psychiatry. It’s similar to taking English course when you’re a premed student. It makes you a better doctor, and in our case, a better psychiatrist. Psychiatry training is not unduly long at 4 years for residency and 1-2 years for fellowship. Instead of shortening training, APA should be working slavishly to increase psychiatrists’ compensation so that a psychiatrist at the end of her fellowship isn’t earning 20%-30% of what her medical school classmate is making at the end of her surgical/cardiology/dermatology/radiology fellowship.

MISKIMEN: The report released by the National Council Medical Director Institute, The Psychiatric Crisis: Causes and Solutions, addressed the “shortage of psychiatrists and the dearth of mental health services in the United States.” I concur with the recommendations offered by the expert panel convened and tasked to discuss this issue. Specifically, implementing the collaborative model of care and leveraging emerging technologies such as telepsychiatry to improve access and open interdisciplinary coordination of care. It is imperative to develop new and innovative payment models shifting away from fee-for-service. As a practicing psychiatrist, I could not agree more with the need to reduce documentation by enhancing technology-based solutions and move to open access scheduling such as same day, next day appointments.

5.

GELLER: In 2019, the average American will still not know that 1) psychiatrists are medical doctors or 2) that psychiatrists and psychologists are different. Even educated Americans often get this wrong. The mass media doesn’t help, mixing these up all the time. My city newspaper only refers to physicians as “doctor.” A PhD psychologist, for example, is “Mr.” or “Ms.” APA should adopt this practice in all its publications and should be working to have this be the rule in all mass media. This would be a huge step forward.

MISKIMEN: I have to point out that, in my view, your organization is off to a great start regarding the rebranding process after the recent name change earlier this year. Case in point, I was at a meeting recently, someone had the program from your annual meeting and I immediately recognized the color and logo from across the room—well done! As you know, the APA recently went through an image refresh including new logo and tag lines which has been successful and well received. There may be opportunities for ACLP and APA to engage in some selective co-branding initiatives.

6.

GELLER: See my response to #4. In addition, APA/ACLP might pose the following study: At one academic medical center in each state, the C-L psychiatrist would see consults as requested. Unless it’s a medical emergency, the C-L psychiatrist will provide her/his consultation the day of the consultation in 25% of the cases, one day later in 25% of the cases, 2 days later in 25% of the cases and 3 days later in 25% of the cases. The outcome measure is the length of the medical/surgical hospitalization. If the medical centers balk, saying this is going to cost them too much money, then there’s a platform to negotiate improved reimbursement. If the study goes forward, and the outcome is as expected, i.e., the longer the delay in the consult report the longer the hospitalization, there’s a platform for negotiation. If the outcome is no difference in the length of hospitalization, then ACLP would need to look at other outcomes to see what the value added is to the patient and to the hospital. Readmission rates is another possible variable to look at. So too would be the frequency of follow-up appointments in the year following hospitalization.

MISKIMEN: Another area of collaboration between the APA and the ACLP should center on the development of credible financial models including full implementation of the new codes for collaborative care management. The APA has conducted benchmarking and other advocacy-related activities to inform efforts to support financial positions for its members. This experience might help with the Academy’s own efforts to be more effective in developing and implementing new financial models. Further, the APA’s Council on Healthcare Systems and Financing, who monitors and evaluates emerging trends in both the public and private sectors, along with its Committee on Integrated Care can aid to elucidate and propose policy changes along with implementing and deploying educational programs to address much needed innovations in financial modeling.